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Am J Clin Nutr. 2018 Apr 1;107(4):626-634. doi: 10.1093/ajcn/nqy007.
Changes in susceptibility to life-threatening infections after treatment for complicated severe malnutrition in Kenya
Ngari MM1,2, Mwalekwa L1, Timbwa M1,2, Hamid F1, Ali R1, Iversen PO3,4, Fegan GW1,5, Berkley JA1,2,6.
1
KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya.
2
The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya.
3
Department of Nutrition, IBM, University of Oslo, Norway.
4
Department of Hematology, Oslo University Hospital, Oslo, Norway.
5
Swansea Trials Unit, Swansea University Medical School, Swansea, United Kingdom.
6
Center for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom.
Abstract
BACKGROUND:
Goals of treating childhood severe acute malnutrition (SAM), in addition to anthropometric recovery and preventing short-term mortality, include reducing the risks of subsequent serious infections. How quickly and how much the risk of serious illness changes during rehabilitation are unknown but could inform improving the design and scope of interventions.
OBJECTIVE:
The aim of this study was to investigate changes in the risk of life-threatening events (LTEs) in relation to anthropometric recovery from SAM.
DESIGN:
This was a secondary analysis of a clinical trial including 1778 HIV-uninfected Kenyan children aged 2-59 mo with complicated SAM, enrolled after the inpatient stabilization phase of treatment, and followed for 12 mo. The main outcome was LTEs, defined as infections requiring rehospitalization or causing death. We examined anthropometric variables measured at months 1, 3, and 6 after enrollment in relation to LTEs occurring during the 6 mo after each of these time points.
RESULTS:
Over 12 mo, there were 823 LTEs (257 fatal), predominantly severe pneumonia and diarrhea. At months 1, 3, and 6, 557 (34%), 764 (49%), and 842 (56%) children had a weight-for-height or -length z score (WHZ) ≥-2, respectively, which, compared with a WHZ <-3, was associated with lower risks of subsequent LTEs [adjusted HRs (95% CIs): 0.50 (0.40, 0.64), 0.30 (0.23, 0.39), and 0.23 (0.16, 0.32), respectively]. However, children with a WHZ ≥-2 at 1, 3, and 6 mo still had 39 (95% CI: 32, 47), 26 (95% CI: 22, 32), and 15 (95% CI: 12, 20) LTEs/100 child-years of observation during the following 6 mo. WHZ at study enrollment predicted subsequent WHZ but not the risk of LTEs. Changes in height-for-age z score did not predict LTEs.
CONCLUSIONS:
Anthropometric response was associated with a rapid and substantial reduction in risk of LTEs. However, reduction in susceptibility lagged behind anthropometric improvement. Disease events, together with anthropometric assessment, may provide a clearer picture of the effectiveness of interventions. Robust protocols for detecting and treating poor anthropometric recovery and addressing broader vulnerabilities that complicated SAM indicates may save lives. This trial was registered at www.clinicaltrials.gov as NCT00934492.